Provider Demographics
NPI:1356997118
Name:SEQUEIRA, EDGARDO A (LSA, CSFA)
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:A
Last Name:SEQUEIRA
Suffix:
Gender:M
Credentials:LSA, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 TUSCANY DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-7066
Mailing Address - Country:US
Mailing Address - Phone:818-471-5979
Mailing Address - Fax:
Practice Address - Street 1:121 TUSCANY DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-7066
Practice Address - Country:US
Practice Address - Phone:818-471-5979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00736246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178570OtherNATIONAL BOARD OF SURGICAL TECHNOLOGY AND SURGICAL ASSISTING
TXSA00736OtherSURGICAL ASSISTANT LICENSE